Ill. Admin. Code tit. 77, § 515.APPENDIX I
List each surgeon by name
Check appropriate requirements met
Signed by CEO/Hospital Administrator
| Surgeon Name | Meets requirements of Section 515.2035(b) or 515.2045(b) | Meets requirements of Section 515.2035(c) or 515.2045(c) | ||||
| Signature Hospital CEO/Administrator | ||||||
| Typed Name Hospital CEO/Administrator | Date | |||||
(Source: Added at 25 Ill. Reg. 16386, effective December 20, 2001)